title: Childhood anemia at high altitude: risk factors for poor outcomes in severe pneumonia.
abstract: BACKGROUND
  Pneumonia is the leading cause of mortality in young children globally, and factors that affect tissue delivery of oxygen may affect outcomes of pneumonia. We studied whether altitude and anemia influence disease severity and outcomes in young children with World Health Organization-defined severe pneumonia.
  
  
  METHODS
  We analyzed data from the SPEAR (Severe Pneumonia Evaluation Antimicrobial Research) study, a World Health Organization- and USAID-sponsored multinational randomized controlled trial of antibiotics for severe pneumonia among children aged 2 to 59 months in resource-poor settings. The trial enrolled 958 children in 8 sites at varying elevations, classified as high (≥ 2000 m) or low (<2000 m) altitude. We compared illness severity and assessed the effect of anemia on treatment outcome at high and low altitudes, adjusting for potential confounders and study site.
  
  
  RESULTS
  Children at high altitudes had significantly lower oxygen saturation on presentation, more cyanosis, lower systolic blood pressure, and higher hemoglobin. After adjusting for potential confounders, anemia predicted treatment failure in children living at high altitude (relative risk: 4.07; 95% confidence interval: 2.60-6.38) but not at low altitude (relative risk: 1.12; 95% confidence interval: 0.96-1.30). Children at high altitude took longer to reach normoxemia than did children at lower altitudes (5.25 vs 0.75 days; P < .0001).
  
  
  CONCLUSIONS
  Children at high altitude present with more severe disease, and children with anemia at high altitude are at greater risk of poor outcome when being treated for severe pneumonia. Given the high global prevalence of anemia among young children, prevention and treatment of anemia should be a priority in children living at high altitude and could improve outcomes of pneumonia.
authors.affiliation: Divisions of Global Health and Pulmonary/Critical Care Medicine, Massachusetts General Hospital, 100 Cambridge St, 15th floor, Boston, MA 02114. pmoschovis@partners.org.
authors.forename: Peter P
authors.initials: PP
authors.lastname: Moschovis
authors.forename: Salem
authors.initials: S
authors.lastname: Banajeh
authors.forename: William B
authors.initials: WB
authors.lastname: MacLeod
authors.forename: Samir
authors.initials: S
authors.lastname: Saha
authors.forename: Douglas
authors.initials: D
authors.lastname: Hayden
authors.forename: David C
authors.initials: DC
authors.lastname: Christiani
authors.forename: Greta
authors.initials: G
authors.lastname: Mino
authors.forename: Mathuram
authors.initials: M
authors.lastname: Santosham
authors.forename: Donald M
authors.initials: DM
authors.lastname: Thea
authors.forename: Shamim
authors.initials: S
authors.lastname: Qazi
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
mesh_terms: D000531:Altitude; D000740:Anemia / Q000453:epidemiology* / Q000628:therapy; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D000860:Hypoxia / Q000453:epidemiology* / Q000628:therapy; D007223:Infant; D038622:Internationality; D008297:Male; D011014:Pneumonia / Q000453:epidemiology* / Q000628:therapy; D012307:Risk Factors; D012720:Severity of Illness Index; D017211:Treatment Failure; D016896:Treatment Outcome
keywords: anemia; high altitude; international child health; pneumonia